CONCEPT ANALYSIS

Medication communication: a concept analysis

Elizabeth Manias

Accepted for publication 9 November 2009

Correspondence to E. Manias:

e-mail: emanias@unimelb.edu.au

Elizabeth Manias MPharm PhD RN

Professor

School of Nursing and Social Work,

The University of Melbourne,

Carlton, Victoria, Australia

MANIAS E. (2010)MANIAS E. (2010) Medication communication: a concept analysis. Journal of

Advanced Nursing 66(4), 933–943.

doi: 10.1111/j.1365-2648.2009.05225.x

AbstractTitle. Medication communication: a concept analysis.

Aim. This paper is a report of a concept analysis of medication communication with

a particular focus on how it applies to nursing.

Background. Medication communication is a vital component of patient safety,

quality of care, and patient and family engagement. Nevertheless, this concept has

been consistently taken-for-granted without adequate analysis, definition or clari-

fication in the quality and patient safety literature.

Data sources. A literature search was undertaken using bibliographic databases,

internet search engines, and hand searches. Literature published in English between

January 1988 and June 2009 was reviewed. Walker and Avant’s approach was used

to guide the concept analysis.

Discussion. Medication communication is a dynamic and complex process. Defin-

ing attributes consider who speaks, who is silent, what is said, what aspects of

medication care are prioritized, the use of body language in conversations, and

actual words used. Open communication occurs if there is cooperation among

individuals in implementing plans of care. Antecedents involve environmental

influences such as ward culture and geographical space, and sociocultural influences

such as beliefs about the nature of interactions. Consequences involve patient and

family engagement in communication, evidence of appropriate medication use, the

frequency and type of medication-related adverse events, and the presence of

medication adherence. Empirical referents typically do not reflect specific aspects of

medication communication.

Conclusion. This concept analysis can be used by nurses to guide them in under-

standing the complexities surrounding medication communication, with the ulti-

mate goal of improving patient safety, quality of care, and facilitating patient and

family engagement.

Keywords: communication, concept analysis, medication management, nursing,

patient engagement, patient safety, quality of care

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 933

J A N JOURNAL OF ADVANCED NURSING

Introduction

Medication communication has emerged in recent times as a

major component of health care. To date, no concept analysis

has been undertaken to clarify the various dimensions of

medication communication and the complexities associated

with this concept in relation to how medications are

managed. In this paper I consider what this concept repre-

sents in an effort to enhance the validity of future research

and practice.

Safe care is at risk because inadequate medication com-

munication leads to medication-related adverse events, which

are recognized as a global problem. The Institute of Medicine

in the United States of America (USA) raised the alarm in

1999 about the crucial link between the incidence of

medication-related adverse events and medication communi-

cation. However, preventable medication-related adverse

events continue to occur regularly and lack of effective

communication is often cited as the major cause (Sutcliffe

et al. 2004, Australian Institute of Health and Welfare &

Australian Commission for Safety and Quality in Health Care

2007, The Joint Commission 2008).

Background

In view of the complexity of treatment regimens, good

medication communication has been identified as the major

way through which safe and effective management of

medications can occur. Medication-related adverse events

are largely associated with lack of appropriate medication

communication among healthcare professionals, and be-

tween healthcare professionals, patients and family members

(Patterson et al. 2004). Good communication about medica-

tions has been emphasized internationally in many govern-

ment reports because of the potential to achieve enormous

economic and health-related benefits. With respect to health-

related benefits, a review of root cause analyses has showed

that, in over 60% of errors, poor communication was an

important cause (World Health Organization (2008). Finan-

cial costs incurred from medication-related adverse events

are enormous, estimated at around US$ 3Æ5 billion/year in

the USA (Institute of Medicine 2006) and A$ 2Æ0 billion/year

in Australia (Alvarez & Coiera 2006). Such costs are likely to

rise further because hospitals are more technologically

capable of keeping sicker patients alive for longer periods.

Enhancing medication communication has been estimated to

save between 15% and 25% of the total cost of hospital care

(Institute of Medicine 2006). Adverse events relating to

medications continue to occur, and a major reason for this

perpetual problem is lack of clarity about how medication

communication manifests in practice (Cox et al. 2004a,

Institute of Medicine 2006, Varpio et al. 2008).

Past research about medication communication has tended

to focus on a paternalistic perspective involving two-way

interactions between a patient and a doctor in a community

practice setting (Ong et al. 1995, Cox et al. 2004a, 2004b).

While this is a simple situation, it is certainly not the most

common one in health care. Patients may decide to discuss

their medication options with family, friends, nurses, phar-

macists, or different doctors before making decisions. There

are also now changing boundaries of responsibilities with

respect to medication management. Due to increasing

specialization of medical roles, doctors are often responsible

for patients in different environments (Mansur et al. 2008).

Therefore, doctors may not be present in any one particular

setting for long periods. There are also increasing subspe-

cialties of allied healthcare professionals, which add to the

intricacy and possible fragmentation of healthcare work

(Varpio et al. 2008). Changing transition points of care

within hospitals and across community settings can also

potentially lead to communication breakdown and medica-

tion errors. Multiple doctors may also be responsible for

managing the same patient who has several, chronic condi-

tions. In addition, pharmacists and nurses have increasing

responsibilities in medication prescribing, counselling and

education (Carey et al. 2008). Patients may therefore consult

with different healthcare professional groups, increasing the

complexity of information conveyed and the number of

possible choices offered (Bartlett et al. 2008, O’Toole 2008).

For patients, medication communication also encompasses

how they interact with family members (Britten 2009).

Despite advances in medication safety research, the mean-

ings associated with medication communication remain

elusive. The significance of the concept analysis presented

here relates to how nurses communicate with patients and

family members about their medication experiences. Nurses

are ideally positioned to listen to patients and family

members, and to deliver effective and safe practice through

vigilant attention to the complexities surrounding medication

communication.

Concept analysis approach

While many frameworks are available to undertake a

concepts analysis (Kim 1987, Rodgers 1989), Walker and

Avant’s (2005) method was employed to explore the concept

of medication communication. The concept analysis consid-

ers how medication communication is used in current

frameworks, and identifies the antecedents, defining attri-

butes and consequences of the concept to determine the

E. Manias

934 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

scientific importance of medication communication to nurs-

ing. The approach involves eight sequential steps: selecting

the concept; clarifying the aim of analysis; identifying uses of

the concept; determining defining attributes; developing

model cases; constructing additional cases; identifying ante-

cedents and consequences; and defining empirical referents.

Data sources

Various bibliographic databases were searched from January

1988 to June 2009 to obtain literature relating to medication

communication. These included Web of Science, CINAHL

Plus, PubMed, PsycINFO and Scopus, using the terms

‘medication communication’, ‘communication’, ‘medication’,

‘medication management’, and ‘medicines management’.

Additional searches involved manually scanning reference

lists of papers already located. Various government reports

were also examined for relevant material. Only papers

published in English that specifically focused on medication

communication were included. Papers in which medication

communication was considered as a practice recommenda-

tion were excluded. The quality of research papers included

in the concept analysis was evaluated using the appraisal

tools of the Critical Appraisal Skills Programme (CASP

2007). An initial search returned 1165 papers, of which 43

specifically examined medication communication.

Results

Select concept and determine purpose

Step 1 of the concept analysis relates to selecting the concept

of interest. In this paper, the aim is to analyse the concept of

medication communication. The second step entails deter-

mining the purpose of the concept analysis. The purpose of

undertaking a concept analysis on medication communica-

tion is to build understanding about the use and application

of the concept and to identify gaps in current knowledge.

Identifying uses of the concept

The third step involves examining uses of the concept of

medication communication. Surprisingly, the literature con-

tains little information about explicit use of the concept.

There are many limitations associated with the uses identified

and the concept is under-developed. The concept has been

used in four ways: examining causal relationships between

medication communication and medication errors; consider-

ing interactions between pharmacists, physicians and patients

to facilitate assessment, care planning and follow-up evalu-

ation; understanding interactions between prescribers, dis-

pensers and patients to facilitate prescribing, medication

taking and dispensing; and exploring interactions between

patients, family members and healthcare professionals in

administration of medication, monitoring of response, and

transfer of information.

The first use involves focusing on decreasing medication

errors, which has been investigated through the Medication

Use Process (Bates et al. 1995). In this process, medication

errors are caused by gaps in medication communication.

Gaps can occur in prescribing or identifying that a medica-

tion needs to be given, transcribing the details of a prescrip-

tion on to a care plan or discharge summary, dispensing

medication from a bulk pharmacy supplier to the patient, and

administering medication. Within this process, patients com-

municate by relaying errors to healthcare professionals. The

importance of family members or informal carers is recog-

nized in their ability to encourage patients to take their

medications, thereby reducing errors. A patient’s decision to

take medications according to the prescriber’s instructions is

another means by which errors are perceived to be reduced.

The second use involves focusing on the Pharmaceutical

Care Process. This is a patient-centred approach incorporat-

ing the pharmacist as the key healthcare professional coor-

dinating medication activities (Cipolle et al. 1998). Three

major activities are associated with patient care: patient

assessment, care plan development and follow-up evaluation.

Assessment involves the pharmacist or physician meeting the

patient to elicit relevant information and making decisions

about rational medication therapy. Development of a care

plan involves establishing goals, selecting appropriate phar-

macological interventions and scheduling future care. Fol-

low-up evaluation involves determining effectiveness or

safety of medication therapy, documenting changes in clinical

status, assessing new problems and scheduling additional

follow-up.

While the Medication Use Process and the Pharmaceutical

Care Process provide some information on medication

communication, they have obvious deficiencies. Communi-

cation appears to be directed by a doctor and pharmacist

determining what information is to be conveyed. No details

are given on how various healthcare professionals commu-

nicate about developing medication goals with each other

and with patients and family members. On the other hand,

the Team Approach to Medication Management (Bajcar

et al. 2005) and the Partnership Approach with the Medicine

Management Cycle [Australian Pharmaceutical Advisory

Council (APAC) 2005] reflect medication communication in

more explicit ways by considering responsibilities and activ-

ities of different players.

JAN: CONCEPT ANALYSIS Medication communication

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 935

The third use involves focusing on the Team Approach to

Medication Management (Bajcar et al. 2005). This approach

was developed to examine the roles and responsibilities of

healthcare professionals in collaborating about medication

practices to bring about desirable patient outcomes. Three

medication practices are associated with the approach:

medication prescribing, medication taking and medication

dispensing. The prescriber is involved in deciding if medica-

tion therapy is needed, selecting the best medication and

monitoring its effectiveness. According to this approach,

patients make informed choices in taking their medications

and evaluating their effectiveness. The dispensing practice

role involves assessing the prescription, making up the

medication, explaining the directions to the patient, and

maintaining an accurate medication profile. The team

approach has come under some scrutiny from Farris (2005),

who criticized it for the limited roles held by healthcare

professionals. The role played by nurses and family members

in medication communication is missing from the approach.

While the importance of medication communication is

implicit, the approach provides no explanatory information

about how interactions between individuals bring about

negotiated decisions and shared responsibilities.

The fourth use involves focusing on the Partnership

Approach with the Medicine Management Cycle, which is

a two-layer model of medication activities (APAC 2005). The

first layer considers various partners associated with medica-

tion communication in terms of recognizing their attitudes,

interests, knowledge and skills. Patients are the focus of all

interactions occurring between doctors, pharmacists, nurses

and carers. The second layer of the approach involves the

medication management pathway and incorporates nine

steps: the decision to prescribe medication, record of the

medication order, review of the medication order, the issue of

medication, provision of medication information, distribu-

tion and storage, administration of medication, monitoring of

response and transfer of verified information. In this path-

way, only the last three steps are identified as involving

medication communication: administration of medication,

monitoring of response and transfer of verified information.

No information is given about how effective medication

communication can be evaluated. Furthermore, the approach

is largely process-driven from the healthcare provider per-

spective, and no consideration is given to how patients’

activities or behaviours influence medication communication.

Defining attributes

The fourth step of the concept analysis involves determining

the defining attributes. The defining attributes of the actual

communication encounter enable determination of whether

effective medication communication occurs (Cox et al.

2004a, Manias et al. 2005). Six defining attributes were

identified (Figure 1). The first involves determining who is

speaking in the communication encounter. It concerns

encouraging involvement of patients, family members, and

healthcare professionals of various disciplines, the views of

whom are complex, context-specific and equally valid (Ste-

venson et al. 2000, Fogel et al. 2006, Seale et al. 2006).

The second attribute involves identifying individuals who

are silent in the communication exchange and the possible

reasons for silences (Spinewine et al. 2005, Moen et al.

2009). Patients have indicated that they readily become silent

if they feel dissatisfied about the extent of communication

exchange with healthcare professionals or if they feel

intimidated. Lack of time to engender trust and mutual

understanding leads to silences, therefore bringing about lack

of opportunities for follow-up questioning (Moen et al.

2009). Silences have also been expressed by healthcare

professionals in relation to lack of communication about

treatment decisions for fear of retribution (Busby & Gilchrist

1992, Manias et al. 2005).

The third attribute involves what is being said to bring

about patient-centred communication. This attribute includes

patients’ right to be informed about what medications they

are taking, how they work and the therapeutic and unwanted

effects they produce. It also involves determining the extent

and type of information to be disclosed to patients (Charles

et al. 1999, Tarn et al. 2008, Karapinar-Carkit et al. 2009,

Tarn et al. 2009).

The fourth attribute involves determining what aspects of

patientcareareprioritizedinrelationtothemedicationregimen.

Consideration is given to patients’ thoughts about their treat-

ment choices and goals (Street et al. 2005, 2007). It also

addresses the impact of the medication regimen on their daily

lives (Pound et al. 2005, Moen et al. 2009, Tarn et al. 2009).

The fifth attribute relates to body language involved in

medication communication interactions. The use of open

body language helps to establish an environment where

patients’ views are valued. On the other hand, a demeanour

that demonstrates lack of interest, a rushed exchange of

information, and attention diverted to other activities is

associated with ineffective medication communication

(Stevenson et al. 2000).

The sixth attribute is the actual words used. It is important

that healthcare professionals use non-technical words to

facilitate understanding, with language chosen tactfully and

carefully. Care is needed to ensure that blame is not

attributed to patients if they are resistant to taking medica-

tions (Hamilton 2004, Pound et al. 2005).

E. Manias

936 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

Presentation of cases to illustrate the concept of

medication communication

Model, borderline and contrary cases are presented in

relation to the openness and effectiveness of the communi-

cation encounter. The cases are based on the following

scenario: Mrs. Brown is a 75-year-old woman who has been

admitted to hospital for unstable angina. Plans are being

made to discharge her in the near future.

Model case

Step 5 of the concept analysis relates to identifying model

cases, which demonstrates use of the defining attributes. A

model case has been developed as explained in the following

example. Healthcare professionals gather around Mrs.

Brown’s bed during the ward round to assess her progress

and plan for her discharge. The physician, charge nurse,

bedside nurse, physiotherapist and pharmacist are in atten-

dance.

Physician: Hello, Mrs. Brown. It is good that your husband is here

too. How are you both today?

Mrs. Brown: I am feeling fine, thank you, doctor.

Mr. Brown: Yes, everything seems to be progressing very well.

Bedside Nurse: Mrs. Brown has been doing extremely well. She is

able to attend to most things herself, with only minimal help.

Charge Nurse: She has not experienced any bouts of chest pain since

her medications were changed.

Pharmacist: Yesterday, we spent a fair amount of time going over

what medications she will be taking at home. Mr. Brown was there as

well, weren’t you?

Mr. Brown: Yes, I was here. I now have a pretty good idea about

what she needs to take.

Physician: That’s great. Do either of you have concerns about

anything?

Mrs. Brown: Well, before yesterday, I wasn’t sure about the Nitro-

Dur (glyceryl trinitrate) patch I had to use. That was probably the

biggest change to my medications because I have never had a patch

before. But now I know what I have to do.

Physiotherapist: I saw Mrs. Brown this morning for her daily routine.

She was able to participate in all activities without any undue exertion.

Mrs. Brown: Yes, we went for a walk around the ward and did some

exercises around the bed just after I took my medications, and I

didn’t feel breathless or get any chest pain.

Physician: We could possibly look at organizing discharge home over

the next day or so, if everyone is okay with that. What do you think,

Mrs. Brown?

Mrs. Brown: I would love to go home soon. I feel confident and ready

to go home.

Antecedents Environmental culture of ward – well-structured ward rounds and handover involving health professionals and patients and lack of negative impact from interruptions. Geographical space (public and private). Time of day and time spent with patient. Sociocultural characteristics of patients (e.g. age, language spoken at home, social supports for managing medications, beliefs about medications). Sociocultural characteristics of health professionals. Healthcare professional-patient relationships – beliefs and values about the nature of the relationship. Interdisciplinary and intradisciplinary relationships – collaborative in nature.

Defining attributes of actual communication encounter Who speaks? – encourage involvement of patient, family members, and all health professionals. Who is silent? – reasons for silences addressed and rectified. What is said? – patient- centred communication. What aspects of patients’ care are prioritised? – consider the patient’s needs. Body language and demeanour of healthcareprofessionals – encourages involvement. Actual words used by healthcare professionals – understood by patient.

Consequences Patients and family members – engagement in shared and active communication rather than passive forms of communication. Evidence of appropriate medication use – medications given on time and in the right way, patients and family members have good understanding and knowledge about medications. Frequency and type of medication-related adverse events. Medication adherence.

Figure 1 Concept of medication communication: antecedents, attributes and consequences for communication about the management of

medications.

JAN: CONCEPT ANALYSIS Medication communication

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 937

Charge Nurse: That should give us plenty of time to organize her

discharge.

Physiotherapist: Tomorrow morning, we can go over what exercises

should be done at home and I can also draw up a plan that I can go

over with you.

Pharmacist: We can go through the medications again, just to make

sure you are clear about everything (looking at Mrs. Brown) and have

them ready for collection just before you go home.

Bedside Nurse: Next time I give you your medications we can also

spend some time on them – making sure you know how to take them.

In this model case, all the defining attributes for open

medication communication are present. Healthcare profes-

sionals are working jointly to plan for the patient’s discharge,

and they feel confident in offering information about the

patient’s progress. Everyone recognizes their responsibility in

this process and each willingly contributes their expertise.

The use of the word ‘we’ also indicates an open communi-

cative approach. Opportunities have been given for the

patient and her husband to express their needs and any

ongoing concerns. All healthcare professionals are continu-

ally focused on the patient in addressing any ongoing

activities that need to be completed prior to discharge.

Borderline case

Step 6 relates to identification of other cases that are clear

examples of borderline or contrary cases of the concept being

analysed. The following is a borderline case of medication

communication. The physician is conducting a bedside ward

round with the charge nurse and pharmacist. The bedside

nurse is not aware of the ward round being conducted and is

showering another patient. The physiotherapist, who has

been managing the patient’s exercise routine since her

admission to the ward, is also not informed about the ward

round and is currently tending to another patient.

Physician: Mrs. Brown, how are you today?

Mrs. Brown: Very well, thank you, doctor.

Consulting Physician: How has Mrs. Brown been doing (turning to

charge nurse)?

Charge Nurse: She has not experienced any bouts of chest pain since

her medications were changed. All her vital signs are stable. Her

serum potassium level was a little on the high side of normal this

morning. What would you recommend?

Physician: Her potassium level can be rechecked tomorrow

morning and we can have her potassium dose readjusted if

needed. We could look at discharge home in the next day or so.

How soon could you organize her medications for discharge

(looking at pharmacist)?

Pharmacist: We could possibly get them organized by tomorrow

afternoon at the earliest. I will need some time to go over all your

medications with you, Mrs. Brown.

Physician: Good, would that work out with you (looking at charge

nurse)?

Charge Nurse: Hopefully. We should be able to organize the

outpatient appointment, the letter for her local doctor and discharge

summary. I will inform the nurse taking care of her that she will be

discharged in the next day or so. I will also ring her husband.

In this borderline case, some of the defining attributes are

present. The consulting physician and charge nurse are

involved in a joint venture, although neither seems particu-

larly interested in asking the patient if she has any current or

ongoing concerns about her condition or medications. There

has been no opportunity for the pharmacist to spend time

educating the patient about her medications. The bedside

nurse, physiotherapist and patient’s husband have not been

involved in the negotiations. What is clearly lacking is a

sharing of expertise and knowledge, especially by the bedside

nurse, pharmacist and physiotherapist, and a lack of

acknowledgement by each healthcare professional for either

their own contribution to the process or that of others. In

borderline situations of communication, healthcare profes-

sionals can engage in various games in an attempt to

overcome deficiencies of communication (Manias & Street

2001). In the game of staging, nurses give physicians

particular information that lead to a specific decision. Nurses

selectively communicate information in stages, encouraging

physicians to make decisions that are favoured by nurses. The

doctor–nurse game, as noted by the charge nurse informing

the physician about the patient’s serum potassium level, is

also used where nurses suggest possible treatments but

communicate this information in a way that appears as

though the suggestion is coming from the physician.

Contrary case

The following is a contrary case of medication communica-

tion. The physician rushes into the ward, and beckons the

charge nurse to conduct a quick ward round with him.

Physician: Okay, Mrs. Brown. Are you having a good day?

Mrs. Brown: Yes, I am fine, doctor.

Physician: Good. (He turns to the charge nurse.) Her condition has

been stable and she hasn’t had any episodes of chest pain since her

admission to the ward. I saw her yesterday and everything seemed to

E. Manias

938 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

be fine then. There is no reason to think that anything has changed. Is

that right?

Nurse Manager: Yes, everything has been going well. There have

been no problems.

Physician: Well, that’s great. I’ll get my resident to organize discharge

for tomorrow. See you later, Mrs. Brown.

Charge Nurse: I will see to it (thinking frantically about contacting

the pharmacist, physiotherapist and bedside nurse about this sudden

course of events).

In this contrary case, there is little evidence of open

communication. The consultant is using close-ended ques-

tions when speaking with the patient and charge nurse. While

he does ask the charge nurse about the patient’s progress,

there is little regard for what the charge nurse might think or

offer as additional knowledge or expertise. Use of the word ‘I’

or ‘my’ is evidence of a self-centred approach on the part of

the physician rather than an open, communicative approach.

There is clearly a hierarchical emphasis in which it is assumed

that the physician has ultimate power and decision-making

ability. There is no involvement with various healthcare

professionals in communicating about the patient’s medical

condition or medications. While it is important to consider

who speaks, who is present, and who is absent, what remains

unsaid and who remains silent are also important (Figure 1).

In contrary cases of communication, unspoken dialogue can

signify disagreements and indecisions in conversations

between healthcare professionals (Manias & Street 2001).

Identifying antecedents and consequences

According to Walker and Avant (2005), the seventh step

involves identifying the antecedents and consequences of the

concept. Antecedents are the aspects considered prior to the

concept occurring, while consequences are the aspects that

are addressed as a result of the concept. The antecedents of

medication communication consist of sociocultural and

environmental influences (Patterson et al. 2004, Manias et al.

2005).

With respect to antecedents, environmental influences

relate to the normative ways in which medication commu-

nication processes are carried out. These influences can

involve formalized and informal formats of communication

through which information transfer occurs (Riley et al.

2007). In some hospital settings, ward rounds are conducted

in a structured and coordinated way, with all healthcare

professionals being encouraged to attend. In other settings,

they are constructed in a haphazard way. They can occur at

different times of the day, and only the head physician and

charge nurse are involved in discussions about plans for care

(Carroll et al. 2008). Geographical space can affect how

communication occurs; for example, if ward rounds are

conducted in the ‘public spaces’ of the bedside, it is possible

for patient and family decision-making to occur. On the other

hand, if ward rounds are conducted in ‘private spaces’ away

from the bedside, it is more likely that patient and family

involvement will not be as apparent. Another environmental

influence is the ways in which interruptions or distractions

impede the transfer of important information during conver-

sations (Pape et al. 2005).

Sociocultural influences of healthcare professionals,

patients and family members can affect how medication

communication occurs through beliefs about how it should

be carried out. Some individuals consider that a cooperative

relationship is a prerequisite for optimal health care, where

shared communication and egalitarianism become antici-

pated processes. Others see the relationship as a pragmatic

process, which is regarded as paternalistic and controlled by

doctors (Cox et al. 2004a, Glintborg et al. 2007). Also

critical are the interdisciplinary relationships between differ-

ent healthcare professionals and intradisciplinary relation-

ships among colleagues of the same professional group

(Manias et al. 2005). Patient characteristics that can have

an impact on medication communication include the lan-

guage spoken by people at home, their different socioeco-

nomic profiles and the presence of multiple, coexisting health

problems (Williams et al. 2008). Healthcare professional

characteristics such as past experience, knowledge in the area

currently practised, and respect for other healthcare profes-

sionals’ contributions influence how they communicate with

colleagues (Manias & Street 2001, Garbutt et al. 2008).

Consequences of medication communication are associated

with outcomes achieved. These can be process-driven or

impact-driven. Process-driven outcomes include the extent to

which healthcare professionals involve patients and family

members in positive engagement through active and shared

forms of communication, as opposed to passive means.

Impact-driven consequences are associated with whether

medications are given in the way they are intended, the

frequency and type of medication-related adverse events

encountered, and whether patients adhere to their medication

regimens (Manias et al. 2005). Actual and potential medica-

tion-related adverse events can occur during ineffective

medication communication at the time of prescription,

supplying, transcription and administration (Lesar et al.

1990, Naylor 2002, Koop et al. 2006). Medication adherence

is another impact-driven consequence. Lack of effective

medication communication can lead to patients reducing

their doses, changing the frequency of administration or

JAN: CONCEPT ANALYSIS Medication communication

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 939

stopping their medications altogether (Peterson et al. 2007,

Wilson et al. 2007).

Defining empirical referents

The eighth and final step in concept analysis is to determine

empirical referents for medication communication. These can

assist in measuring concepts and therefore validating their

existence and importance (Walker & Avant 2005). While

empirical referents are extensively available to measure

communication, few approaches have been developed that

consider medication communication.

An extensive array of communication instruments have

been tested for validity and reliability (Shortell et al. 1991,

Schmidt & Svarstad 2002). While these instruments may

provide a mapped trajectory of characteristics affecting

communication, healthcare professionals are represented in

fixed ways. That is, the importance of clinical context, nature

and dynamics of the situation, type of knowledge and

sociocultural aspects remain unexplored. Alvarez and Coiera

(2006) have developed a structured observation tool to

capture information about with whom the healthcare pro-

fessional is communicating, channel of communication,

purpose of interaction, type of interaction, number and type

of interruptions occurring during communication, and who

initiates the communication. However, this tool is generic

and does not specifically focus on medication communica-

tion.

Tools have rarely been developed that explicitly examine

medication communication. Baumann et al. (2008) devel-

oped the Therapeutic Communications Skills of General

Practitioners Scale, which has shown that improved medica-

tion communication is positively associated with patients’

perceptions of their adherence. Unfortunately, this scale only

considers communication between a general practitioner and

patient, and does not examine other antecedents that

may have an impact on a patient’s medication-taking

behaviour.

Discussion

A limitation of this concept analysis is the relative lack of

research undertaken by nurses examining medication com-

munication. Most work has been generated from disciplines

outside of nursing, in particular from pharmacy and medi-

cine. Since the concept is relatively new, it will continue to be

refined at a rapid pace. Limitations of the Walker and Avant

(2005) approach include possible simplification of the process

involved. There is also an emphasis on consistency of concept

use across contexts at the expense of comprehending how the

What is already known about this topic

• Good communication is vital for achieving safe and

effective management of medications.

• Medication communication is a relatively new concept

emerging from the quality and patient safety literature

within the last decade.

• Walker and Avant’s concept analysis methodology is a

standardized approach for clarifying antecedents,

attributes and consequences of a concept.

What this paper adds

• The defining attributes of medication communication

are: identifying who is speaking in the communication

encounter; identifying the individuals who are silent in

the communication exchange and possible reasons for

silences; examining what is being said to engender

patient-centred communication; determining what

aspects of patients’ care are prioritized; examining the

body language involved in medication communication;

and identifying the actual words used to facilitate

understanding.

• The antecedents of communication in medication

management consist of sociocultural and environmental

while consequences occur through process and impact-

related outcomes, such as the extent of active commu-

nication by patients and family members and the inci-

dence of medication-related adverse events.

• Open communication occurs if there is cooperation

among healthcare professionals, patients and family

members about making shared decisions, implementing

the plan of care, and recognizing the contribution of

others in medication-related interactions.

Implications for practice and/or policy

• The concept analysis considers the complex dynamics of

medication communication, which will help to bring

about safe medication management and patient and

family engagement.

• By evaluating the presence and influence of antecedents,

nurses can identify those patients or family members at

risk of not having the opportunity to participate in

medication decisions.

• Nurses can determine the extent of interdisciplinary

involvement in medication communication, and take

steps to encourage participation among different

healthcare professionals.

E. Manias

940 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

concept fits with other aspects of interest in nursing (Hupcey

et al. 1996, Weaver & Mitcham 2008).

The attributes, antecedents and consequences of medica-

tion communication represent a new middle-range theory in

terms of scope, level of abstraction and alliance to empirical

findings (Smith & Liehr 2008). The theory underpinning

medication communication has a relatively broad scope of

phenomena that are of concern to the nursing profession. The

level of abstraction of the concept locates medication

communication between grand theories and situation-specific

theories. In particular, the components comprising medica-

tion communication are more concrete and circumscribed

than nursing communication or interactional theories at a

higher level of abstraction, such as the Intersystem Model

(Artinian 1991). The Intersystem Model is a grand theory at

the same level of abstraction as Margaret Newman’s Theory

of Health as Expanding Consciousness or Parse’s Theory of

Human Becoming, rather than at the more abstract level of a

conceptual model, such as Roy’s Adaptation Model or Betty

Neuman’s Systems Model. Artinian’s Intersystem Model is

based on three components of interactions that occur

between patients and nurses: the detector, which processes

information and knowledge, the selector, which considers the

attitudes and values of individuals, and the effector, which

identifies behaviours relevant to a situation. When compared

to the antecedents of medication communication, these three

components of the Intersystem Model are conceptualized

from a more abstract perspective. Conversely, the compo-

nents of medication communication are more abstract than

mere descriptions of actual practice involving nurses’ man-

agement of medications. The concept of medication commu-

nication is functionally applicable to empirical findings, and

its dimensions have been generated from past research

(Manias et al. 2005). In addition, this middle-range theory

can be applied to a variety of practice populations and

environments.

Conclusion

The concept analysis was undertaken to clarify the complex

influences around medication communication, to nullify

ambiguities in relation to these influences, and to promote

understanding of how the findings can be used in health care

practice and research. Clarifying the concept is important in

terms of helping nurses to assess patients’ medication needs

more accurately. By evaluating the presence and influence of

antecedents, nurses can identify those patients or family

members at risk of not having the opportunity to participate

in medication communication. Nurses can use the defining

attributes to determine the extent of interdisciplinary involve-

ment in medication communication, and to take steps to

encourage participation among healthcare professionals. It is

possible to consider the complex dynamics of how individuals

interact about medications, and the consequences achieved in

relation to these interactions.

Research should focus on examining diverse patient

population groups, and how medication communication

processes can be altered to address people’s needs. Changes

in sociocultural influences of different healthcare profession-

als and environmental dynamics of various contexts should

be investigated to accurately determine their effects on

medication communication. Further work is also needed on

developing tools to measure medication communication in

actual practice.

Funding

Funding was received from the Australian Research Council

through a Discovery Grant to conduct this research (grant

number: DP0771068).

Conflict of interest

No conflict of interest has been declared by the author.

References

Alvarez G. & Coiera E. (2006) Interdisciplinary communication: an

uncharted source of medical error. Journal of Critical Care 21,

236–242.

Artinian B.M. (1991) The development of the intersystem model.

Journal of Advanced Nursing 16, 164–205.

Australian Institute of Health and Welfare (AIHW) & Australian

Commission for Safety and Quality in Health Care (ACSQHC)

(2007) Sentinel Events in Australian Public Hospitals 2004-05.

AIHW, Canberra.

Australian Pharmaceutical Advisory Council (APAC) (2005) Guiding

Principles to Achieve Continuity in Medication Management

for Health Professionals. Australian Department of Health and

Ageing, Canberra.

Bajcar J.M., Kennie N. & Einarson T.R. (2005) Collaborative

medication management in a team-based primary care practice: an

explanatory conceptual framework. Research in Social and

Administrative Pharmacy 1, 408–429.

Bartlett G., Blais R., Tamblyn R., Clermont R.J. & MacGibbon B.

(2008) Impact of patient communication problems on the risk of

adverse events in acute care settings. Canadian Medical Associa-

tion Journal 178, 1555–1562.

Bates D.W., Cullen D.J., Laird N., Petersen L.A., Small S.D., Servi

D., Laffel G., Sweitzer B.J., Shea B.F., Hallisey R., Vliet M.V.,

Nemeskai R. & Leape L.L. (1995) Incidence of adverse drug

events and potential adverse drug events: implications for pre-

vention. Journal of the American Medical Association 274,

29–34.

JAN: CONCEPT ANALYSIS Medication communication

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 941

Baumann M., Baumann C., Le Bihan E. & Chau N. (2008) How

patients perceive the therapeutic communications skills of their

general practitioners, and how that perception affects adherence:

use of the TCom-skill GP scale in a specific geographical area.

BMC Health Services Research 8, 244. doi:10.1186/1472-6963-8-

244.

Britten N. (2009) Medication errors: the role of the patient. British

Journal of Clinical Pharmacology 67, 646–650.

Busby A. & Gilchrist B. (1992) The role of the nurse in the medical

ward round. Journal of Advanced Nursing 17, 339–346.

Carey N., Courtney M., James J., Hills M. & Roland J. (2008) An

evaluation of a diabetes specialist nurse prescriber on the system of

delivering medicines to patients with diabetes. Journal of Clinical

Nursing 17, 1635–1644.

Carroll K., Iedema R. & Kerridge R. (2008) Reshaping ICU ward

round practices using video-reflexive ethnography. Qualitative

Health Research 18, 380–390.

Charles C., Gafni A. & Whelan T. (1999) Decision-making in the

physician-patient encounter: revisiting the shared treatment deci-

sion-making model. Social Science & Medicine 49, 651–661.

Cipolle R.J., Strand L.M. & Morley P.C. (1998) Pharmaceutical

Care Practice. McGraw-Hill, New York.

Cox K., Stevenson F., Britten N. & Dundar Y. (2004a) Task Force on

Medicines Partnership Briefing. Medicines Partnership, London.

Cox K., Stevenson F.A., Britten N. & Dundar Y. (2004b) A Sys-

tematic Review of Communication Between Patients and Health

Care Professionals about Medicine-Taking and Prescribing. Med-

icines Partnership, London.

Critical Appraisal Skills Programme (CASP) (2007) Critical Apprai-

sal Skills Programme Appraisal Tools. Retrieved from http://

www.phru.nhs.uk/Pages/PHD/resources.htm on 8 January 2009.

Farris K.B. (2005) Relationships and responsibilities are critical to

team care in medication management. Research in Social and

Administrative Pharmacy 1, 369–374.

Fogel T.P., Todd M.W., Wilson P.C. & Como J.A. (2006) Meeting

JCAHO medication management standards: getting everyone in-

volved. Hospital Pharmacy 41, 1090–1100.

Garbutt J., Waterman A.D., Kapp J.M., Dunagan W.C., Levinson

W., Fraser V. & Gallagher T.H. (2008) Lost opportunities: how

physicians communicate about medical errors. Health Affairs 27,

246–255.

Glintborg B., Andersen S.E. & Dalhoff K. (2007) Insufficient com-

munication about medication use at the interface between hospital

and primary care. Quality and Safety in Health Care 16, 34–39.

Hamilton H. (2004) Symptoms and signs in particular: the influence

of the medical concern on the shape of physician-patient talk.

Communication & Medicine 1, 59–70.

Hupcey J.E., Morse J.M., Lenz E.R. & Tason M.C. (1996) Wilsonian

methods of concept analysis: a critique. Inquiry for Nursing

Practice: An International Journal 10, 185–210.

Institute of Medicine (2006) Preventing Medication Errors. Institute

of Medicine, Washington, DC.

Karapinar-Carkit F., Borgsteede S.D., Zoer J., Smit H.J., Egberts

A.C.G. & van den Bernt P.M.L.A. (2009) Effect of medication

reconciliation with and without patient counseling on the num-

ber of pharmaceutical interventions among patients discharged

from the hospital. The Annals of Pharmacotherapy 43, 1001–

1010.

Kim H.S. (1987) Collaborative decision-making with clients. In

Clinical Judgment and Decision Making: The Future with Nursing

Diagnosis (Hannah K., Reimer M., Mills W. & Letoureau S., eds),

Wiley, New York, pp. 58–62.

Koop B.J., Erstad B.L., Allen M.E., Theodorou A.A. & Priestley G.

(2006) Medication errors and adverse drug events in an intensive

care unit: direct observational approach for detection. Critical

Care Medicine 34, 415–425.

Lesar T.S., Briceland L., Delcoure K., Parmalee J.C., Masta-Gornic

V. & Pohl H. (1990) Medication prescribing errors in a teaching

hospital. Journal of the American Medical Association 263, 2329–

2334.

Manias E. & Street A. (2001) The interplay of knowledge and

decision making between nurses and doctors in critical care.

International Journal of Nursing Studies 38, 129–140.

Manias E., Aitken R. & Dunning T. (2005) Graduate nurses’ com-

munication with health professionals when managing patients’

medications. Journal of Clinical Nursing 14, 354–362.

Mansur N., Weiss A. & Beloosesky Y. (2008) Relationship of

in-hospital medication modifications of elderly patients to post-

discharge medications, adherence, and mortality. Annals of Phar-

macotherapy 42, 783–789.

Moen J., Bohm A., Tillenius T., Antonov K., Nilsson J.L.G. &

Ring L. (2009) ‘‘I don’t know how many of these [medicines]

are necessary’’ – A focus group study among elderly users of

multiple medicines. Patient Education and Counseling 74, 135–

141.

Naylor R. (2002) Medication Errors: Lessons for Education and

Healthcare. Radcliffe Medical Press, Abingdon.

O’Toole G. (2008) Communication: Core Interpersonal Skills for the

Health Professionals. Churchill Livingstone, Chatswood.

Ong L.M.L., De Haes J.C.J.M., Hoos A.M. & Lammes F.B. (1995)

Doctor-patient communication: a review of the literature. Social

Science & Medicine 40, 903–918.

Pape T.M., Guerra D.M., Muzquiz M., Bryant J.B., Ingram M.,

Schranner B., Alcala A., Sharp J., Bishop D., Carreno E. & Welker

J. (2005) Innovative approaches to reducing nurses’ distractions

during medication administration. The Journal of Continuing

Education in Nursing 36, 108–116.

Patterson E.S., Cook R.I., Woods D.D. & Render M.L. (2004)

Examining the complexity behind a medication error: generic

patterns in communication. Systems and Humans 34, 749–756.

Peterson A.M., Nau D.P., Cramer J.A., Benner J., Gwadry-Sridhar F.

& Nichol M. (2007) A checklist for medication compliance and

persistence studies using retrospective databases. Value in Health

10, 3–12.

Pound P., Britten N., Morgan M., Yardley L., Pope C., Daker-White

G. & Campbell R. (2005) Resisting medicines: a synthesis of

qualitative studies of medicine taking. Social Science & Medicine

61, 133–155.

Riley R., Forsyth R., Manias E. & Iedema R. (2007) Whiteboards:

mediating professional tensions in clinical practice. Communica-

tion & Medicine 4, 165–175.

Rodgers B.L. (1989) Concepts, analysis, and the development of

nursing knowledge. Journal of Advanced Nursing 14, 330–335.

Schmidt I.K. & Svarstad B.L. (2002) Nurse-physician communica-

tion and quality of drug use in Swedish nursing homes. Social

Science & Medicine 54, 1767–1777.

E. Manias

942 � 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd

Seale C., Chaplin R., Lelliott P. & Quirk A. (2006) Sharing decisions

in consultations involving anti-psychotic medication: a qualitative

study of psychiatrists’ experiences. Social Science & Medicine 62,

2861–2873.

Shortell S.M., Rousseau D.M., Gillies R.R., Devers K.J. & Simons

T.L. (1991) Organisational assessment in intensive care units

(ICUs): construct development, reliability, and validity of the ICU

nurse-physician questionnaire. Medical Care 29, 709–726.

Smith M.J. & Liehr P.R. (eds) (2008) Middle Range Theory for

Nursing, 2nd edn. Springer, New York.

Spinewine A., Swine C., Dhillon S., Franklin B.D., Tulkens P.M.,

Wilmotte L. & Lorant V. (2005) Appropriateness of use of medi-

cines in elderly inpatients: qualitative study. British Medical

Journal 331, 935–940.

Stevenson F.A., Barry C.A., Britten N., Barber N. & Bradley C.P.

(2000) Doctor-patient communication about drugs: the evidence for

shared decision making. Social Science & Medicine 50, 829–840.

Street R.L. Jr, Gordon H., Ward M.M., Krupat E. & Kravitz R.L.

(2005) Patient participation in medical consultations: why some

patients are more involved than others. Medical Care 43, 960–969.

Street R.L. Jr, Gordon H. & Haidet P. (2007) Physicians’ communi-

cation and perceptions of patients: is it how they look, how they talk,

or is it just the doctor? Social Science & Medicine 65, 586–598.

Sutcliffe K.M., Lewton E. & Rosenthal M.M. (2004) Communica-

tion failures: an insidious contributor to medical mishaps. Aca-

demic Medicine 79, 186–194.

Tarn D.M., Heritage J. & Paterniti D.A. (2008) Prescribing new

medications: a taxonomy of physician-patient communication.

Communication & Medicine 5, 195–208.

Tarn D.M., Paterniti D.A., Williams B.R., Cipri C.S. & Wenger N.S.

(2009) Which providers should communicate which critical

information about a new medication? Patient, pharmacist, and

physician perspectives. Journal of the American Geriatrics Society

57, 462–469.

The Joint Commission (2008) Sentinel event alert: behaviors that

undermine a culture of safety. Sentinel Event Alert 40 (July 9),

Retrieved from http://www.jointcommission.org/SentinelEvents/

SentinelEventAlert/ on 17 July 2009.

Varpio L., Hall P., Lingard L. & Schryer C.F. (2008) Interpro-

fessional communication and medical error: a reframing of re-

search questions and approaches. Academic Medicine 83,

S76–S81.

Walker L.O. & Avant K.C. (2005) Strategies for Theory Construc-

tion in Nursing, 4th edn. Pearson Prentice Hall, Upper Saddle

River, NJ.

Weaver K. & Mitcham C. (2008) Nursing concept analysis in North

America: state of the art. Nursing Philosophy 9, 180–194.

Williams A., Manias E. & Walker R. (2008) Adherence to multiple,

prescribed medications in diabetic kidney disease: a qualitative

study of consumers’ and health professionals’ perspectives. Inter-

national Journal of Nursing Studies 45, 1742–1756.

Wilson I.B., Schoen C., Neuman P., Strollo M.K., Rogers W.H.,

Chang H. & Safran D.G. (2007) Physician-patient communication

about prescription medication nonadherence: a 50-state study of

America’s seniors. Journal of General Internal Medicine 22(1), 6–

12.

World Health Organization (2008) World Alliance for Patient Safety:

Learning from Error. World Health Organization, Geneva.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the

advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and

scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management

or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers.

For further information, please visit the journal web-site: http://www.journalofadvancednursing.com

Reasons to publish your work in JAN

High-impact forum: the world’s most cited nursing journal within Thomson Reuters Journal Citation Report Social

Science (Nursing) with an Impact factor of 1Æ654 (2008) – ranked 5/58.

Positive publishing experience: rapid double-blind peer review with detailed feedback.

Most read journal globally: accessible in over 6,000 libraries worldwide with over 3 million articles downloaded online

per year.

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan with publication within 9

months from acceptance.

Early View: quick online publication for accepted, final and fully citable articles.

JAN: CONCEPT ANALYSIS Medication communication

� 2010 The Author. Journal compilation � 2010 Blackwell Publishing Ltd 943